3 Lecce, a beloved husband and father, inside the campus of Sierra Tucson, a for-profit
4
residential behavioral health hospital. Mr. Lecce’s death, on January 23, 2015, was the
5
fifth preventable death that has occurred inside Sierra Tucson as a result of leadership and
6
7 staff failures to comply with Arizona regulations, its own internal policies and

8 procedures, the standard of care, and basic common sense. Subsequent to Mr. Lecce’s

death, another individual died under substantially similar circumstances on August 27,
10
2015, bringing the fatality total to six. Sierra Tucson is in the midst of what the medical
11
12 literature describes as a “suicide cluster.”

13 Mr. Lecce borrowed money from his extended family and, after seeking support
14
and encouragement from his wife and children, travelled across the country to Sierra
15
Tucson. He sought help and treatment for debilitating neuropathy pain and related
16
17 depression and brain health problems. He and his family placed their complete trust, and

18 indeed Mr. Lecce’s life, in Sierra Tucson and its promises.
19
The account, from Sierra Tucson’s records, is that Mr. Lecce was having thoughts
20
of suicide and feelings of total hopelessness that triggered his transfer to a heightened
21
22 state of supervision and care. In the days before his death, absent any documentation of

2
Later, on January 17, 2015, Mr. Lecce reported thoughts of suicide and feelings of
1
2 total helplessness. It was ordered that he be provided with increased supervision and care

3 via transfer to the facility’s intensive Level 1 hospital. That did not happen. On January
4
19, Mrs. Lecce called Sierra Tucson concerned about a call from Mr. Lecce where he told
5
her, “I’m just calling to tell you goodbye.” She was worried about how he sounded on
6
7 the phone. Emails suggest Defendant Sierra Tucson placed Mr. Lecce on a “discharge

8 contract” the next day.

On January 23, 2015, the date of his death, no one at Sierra Tucson evaluated Mr.
10
Lecce or engaged with him until he was found, near death, in his bedroom in the

12 afternoon. Sierra Tucson’s repeated failures to engage with Mr. Lecce, or even look for

13 him after he was absent at all five of his daily appointments, violates the standard of care
14
and Sierra Tucson’s own “Amber Alert” patient tracking policy. The Defendants’
15
irresponsible and unreasonable actions and decisions coupled with a lack of supervision
16
17 and accountability caused Mr. Lecce’s death. This action is based in negligence and

23 controlled by Acadia Healthcare. Sierra Tucson is authorized to do business and does
24
business in the State of Arizona. It is located ii Pinal County, and it does business
25
throughout the State of Arizona, including in Pima County, where it has a prominent
26

3 all of the employees and agents, whether party or non-party to this action, done in the
4
course and scope of their employment relationship with Defendant Sierra Tucson.
5
Defendant Reinier J. Diaz, M.D. is a medical doctor practicing in the
6
7 greater Tucson area. At all times relevant to this action, Dr. Diaz was working as an

8 agent and/or employee of Defendant Sierra Tucson, which is vicariously liable for all acts

and omissions complained of herein.
10
4. At all times relevant to this action, Dr. Diaz was assigned by Sierra Tucson

12 as Mr. Lecce’s attending physician.

13 5. Upon information and belief, Defendant Diaz is not board certified in any
14
medical specialty by the American Board of Medical Specialties.
15
6. Defendant Diaz is a resident of Pima County, Arizona.
16
17 7. At all times relevant to this action, Defendant Scott R. Davidson was an

18 employee and/or agent of Defendant Sierra Tucson, which is vicariously liable for his
19
acts and omissions complained of herein.
20
8. On January 23, 2015, the day of Mr. Lecce’s death, Defendant Davidson
21
22 was the nurse assigned to the care of Mr. Lecce.

23 9. Defendant Davidson is a resident of Pima County, Arizona.
24
10. At all times relevant to this action, Defendant Kelley Anderson was an
25
agent and/or employee of Defendant Sierra Tucson, which is vicariously liable for her
26

4
acts and omissions complained of herein.

2 11. On January 23, 2015, Defendant Anderson was the Clinical Technician

3 assigned to provide Patient Care Assistance to Mr. Lecce.
4
12. Defendant Anderson is a resident of Pima County, Arizona.
5
13. Plaintiff Lindsey Lecce is the widow and surviving statutory beneficiary of
6
7 Richard Lecce. The two had been married for 28 years when Richard Lecce died inside

8 Sierra Tucson on January 23, 2015.

14. Mrs. Lecce brings this action on her own behalf, and on behalf of their two
10
children, son Garrett Lecce and daughter Morgan Lecce. She also brings this action on

21. Defendant Sierra Tucson promises that “When you enter treatment with us,
10
you can rest assured that you will receive the quality medical care that you deserve every

12 single day. The team of skilled and dedicated full-time medical professionals

13 communicates and collaborates with the entire treatment team. This ensures that patient
14
care is always provided in a comprehensive and highly coordinated manner.”
15
22. Defendant Sierra Tucson holds itself out as specializing in the treatment of
16
17 co-occurring or co-morbid disease and disorders.

18 23. In October 2014, Acadia Health Care announced it would acquire Sierra
19
Tucson, along with a portfolio of other behavioral health facilities that were assets of
20
CRC health group for 1.8 billion dollars.
21
22 24. At all times relevant to this action, Defendant Sierra Tucson, under the

23 ownership of Acadia, held itself out as being an appropriate — if not the best — facility for
24
the treatment of anxiety and depression co-occurring with pain.
25
25. Defendant Sierra Tucson held itself out as an appropriate — if not the best
26
—

6
facility to address the needs of severely depressed individuals who expressed either past
1
2 or recent suicidal ideation.

3 26. Defendant Sierra Tucson charges patients, including Mr. Lecce and others,
4
upward of $1,300 per day for their room and treatment.
5
27. The Sierra Tucson campus is made up of two separate facilities. There is a
6
7 Level One psychiatric hospital, which operates under license SH3764. There is also a

8 residential facility that operates under license BH3923.

28. During the course of a patient’s stay on the Sierra Tucson campus, a patient
10
is initially admitted into the Level One facility for evaluation and close observation.

12 29. If and when appropriate, the patient is discharged from the Level One

13 facility and admitted into the Level Two facility.
14
30. Both facilities operate under the name Sierra Tucson.
15
31. During a patient’s stay inside the Sierra Tucson gates, they can be admitted,
16
17 discharged and readmitted between a Level One and Level Two facility on an as-needed

18 basis, depending on clinical and observational factors and professional judgment.
19
32. Because the two license holding entities are distinct and separate and
20
operate under distinct and separate licenses, a patient must be admitted and discharged
21
22 with corresponding paperwork, chart entries and documentation.

23 B. The State of Arizona Department of Health Services Enforcement Actions

33. Subsequent to Mr. Lecce’s death, the State of Arizona Department of

7
Sierra Tucson’s Level One facility (SH3764), and the other centered on Sierra Tucson’s
1
2 Level Two facility (BH3923).

3 34. Both investigations found deficiencies including violations of Arizona
4
regulations and violations of Sierra Tucson’s professional bylaws, policies, and
5
procedures.
6
7 35. The State entered Enforcement Actions against both of Sierra Tucson’s

8 licenses and required the facility to come forward with acceptable Plans of Correction.
9
a. The Level Two Investigation
10
36. Defendant Sierra Tucson entered into an informal dispute process with state

12 regulators with regard to the Level Two findings.

13 37. As a result of those private negotiations, Sierra Tucson convinced state
14
regulators to modify at least one Survey Finding in the final report.
15
38. The initial subject Survey Finding, published on www.azcarecheck.com on
16
17 April 20, 2015, read:

18 Based on document reviews and interviews, the administrator
19 failed to ensure that the policy and procedure for behavioral health
services of tracking residents was implemented to protect the
20 health and safety of five out of five sampled residents and
contributing the death of one out of five sampled residents.”
21 [Emphasis added.]
22
39. In the April 20, 2015 version, the State made a finding that Sierra Tucson’s
23
failures contributed to Mr. Lecce’ s death.
24
25 40. Through the informal dispute resolution process, Defendant Sierra Tucson
26 agreed to certain sanctions and actions.

8
41. In exchange, state regulators agreed to remove the phrase that Sierra
1
2 Tucson’s failures “contribut[ed] to the death of one [Mr. Lecce] of five sampled

8 LICENSEE AGREED TO PAY $7500 iN CIVIL PENALTIES
9 FOR FAILURE TO IMPLEMENT POLICIES AND
PROCEDURES THAT COVER RESIDENT OUTiNGS. IF
10 RESIDENTS DO NOT ATTEND, EITHER AN AUTOMATIC
SAFETY CHECK OR A CHECK AFTER A 15-MINUTE DELAY
11
SHOULD HAVE BEEN IMPLEMENTED; TREATMENT
12 PLANS WERE NOT ESTABLISHED FOR RESIDENTS WHEN
THEY MOVED FROM THE HOSPITAL TO THE
13 RESIDENTIAL FACILITY FOR FIVE RESIDENTS; AND
14 TREATMENT PLANS WERE NOT REVIEWED BY A
BEHAVIORAL HEALTH PROFESSIONAL WITHIN 24 HOURS
15 OF COMPLETION FOR FIVE RESIDENTS. THE
DEPARTMENT IS SUED A PROVISIONAL LICENSE
16 EFFECTIVE FROM JUNE 10, 2015 TO OCTOBER 31, 2015.
17 LICENSEE AGREED TO RETURN THE ORIGINAL
STATEMENT OF DEFICIENCIES WITH THE SIGNED AND
18 DATED ACCEPTABLE PLAN OF CORRECTION TO THE
19 DEPARTMENT WITHIN 10 WORKING DAYS OF RECEIPT OF
THE ENFORCEMENT AGREEMENT.
20
43. In its survey leading to the June 10, 2015 Enforcement Action, state
21
22 investigators interviewed Sierra Tucson employees, including but not limited to Scott

23 Davidson, Mr. Lecce’s assigned nurse on the date of his death, and Kelley Anderson, his
24
assigned Patient Care Tech, along with the residential staff and program staff responsible
25
for leading group activities and group sessions.
26

9
44. Per the State’s investigation, on January 23, 2015, Mr. Lecce did not have a
1
2 mandatory morning meeting with Defendant Davidson, his assigned nurse. Defendant

3 Davidson described these meetings as “very important because they bring him contact
4
with the resident and he can see how they are feeling each day.”
5
45. When asked why he did not track down Mr. Lecce, or any resident who
6
7 misses the morning meeting, Defendant Davidson replied, “It is not in my job description

8 to track down people. The patient comes to the nurse. We have too many other things to

do that only the nurse can do.”
10
46. Per the State’s investigation, on January 23, 2015, Mr. Lecce was absent

12 and/or there was no documentation as to his attendance at breakfast, his 0715 Exercise

18 48. Defendant Davidson and Defendant Anderson, and other Sierra Tucson
19
employees, reported to state investigators that Mr. Lecce had not been seen on the day of
20
his death and there was “no urgency” in looking for him.
21
22 49. Defendant Anderson, in particular, told investigators that she “assumed”

23 Mr. Lecce had been located by his 1000 session because she never received word that he
24
was absent.
25
50. In connection with Sierra Tucson losing track of Mr. Lecce and his
26

3 51. Sierra Tucson staff admitted that they were “not aware” of requirements to
4
take attendance and report absence.
5
52. Multiple staff interviewed by state regulators confirmed that they “were not
6
7 sure who was responsible” for taking attendance, reporting absences, and calling for a

8 search.
9
b. The Level One Investigation
10
53. On October 1, 2015, the State entered an Enforcement Action against Sierra

13 54. The State assessed an agreed to $1,000 fine, along with the following
14
statement:
15
LICENSEE AGREED TO PAY $1000 iN CIVIL PENALTIES.
16 THE MEDICAL STAFF MEMBER FAILED TO COMPLY
17 WITH THE BY-LAWS OF THE PROFESSIONAL STAFF iN
PROVIDING QUALITY PATIENT CARE, WHEN A PATIENT
18 WHO PRESENTED WITH A HISTORY OF SUICIDAL
19 IDEATION RELATED TO MOOD AND PAIN, DID NOT
RECEIVE A PAIN CONSULT TIMELY; AND THE NURSE
20 EXECUTIVE FAILED TO ENSURE THE RN WHO
FACILITATED THE TRANSFER OF A PATIENT TO A
21 LOWER LEVEL OF CARE, WHILE ON A 1:1 FOR SAFETY
22 DUE TO RISK OF SUICIDE, DID NOT NOTIFY THE
PHYSICIAN OF THE PATIENT’S STATUS REQUIRING 1:1
23 OBSERVATION PRIOR TO THE TRANSFER. LICENSEE
24 AGREED TO RETURN THE ORIGINAL STATEMENT OF
DEFICIENCIES WITH THE SIGNED AND DATED
25 ACCEPTABLE PLAN OF CORRECTION TO THE
DEPARTMENT WITHIN 10 WORKING DAYS OF RECEIPT
26 OF THE ENFORCEMENT AGREEMENT.

11
1
55. In a survey of the Level One facility dated July 22, 2015, state regulators
2
determined that Sierra Tucson failed to insure that medical staff provide quality care to

Mr. Lecce as evidenced by, among other things, its failing to conduct a psychiatric

5 evaluation of him before discharging him from the Level One facility to the lower level
6
of care Level Two facility shortly before his death.
7
56. This undocumented discharge was in violation of Sierra Tucson’s own
8
hospital policy/procedure titled “Admission Criteria.”

10 57. This undocumented discharge was done even though Mr. Lecce was
11
documented to be at a high risk of suicide at the time he was transferred to the residential
12
facility.
13
14 c. The Amber Alert Policy

21 60. The policy requires staff be responsible for knowing the whereabouts of
22
their residents, which includes the responsibility to monitor resident movement, locate
23
residents when not accounted for, and participate in Amber Alert searches.
24
25 61. The policy requires staff take attendance for each activity on the day’s
26 schedule. If a resident is not in attendance as scheduled, the locating procedure, also

3 guidance to employees in the event that a patient is absent from a scheduled activity.
4
63. Per the policy, if a resident is absent from two consecutive activities, the
5
Treatment Team will be notified to discuss the implementation of behavioral
6
7 interventions.

8 64. On January 23, 2015, Mr. Lecce was absent from all of his scheduled

activities of the day, and his assigned nurse did not have his required morning
10
engagement with Mr. Lecce.
11
12 65. On January 23, 2015, Defendant Sierra Tucson, through its staff, including

13 but not limited to the named defendants, failed to act in accord with its Amber Alert
14
policy.
15
66. The failures alleged herein are alleged against Sierra Tucson,
16
17 independently, and against several of those hired by Sierra Tucson to care for Mr. Lecce.

18 67. The failures alleged herein caused and contributed to Mr. Lecce’s death on
19
January 23, 2015, but they are examples of a much larger, ongoing pattern of negligence
20
and conscious disregard of substantial risk of catastrophic harm to a very vulnerable
21
22 population, their own patients and their families.

13
families, including Mr. Lecce and his family, a duty to use due care in their diagnosis,
1
2 treatment, documentation of care and supervision of him. Additionally, Defendants owed

3 Mr. Lecce a duty to use due care in their education, training, instruction and supervision
4
of employees as relates to the care and treatment of patients, the creation and
5
maintenance of records and compliance with government statutes and/or regulations and
6
7 the policies and procedures of the Sierra Tucson facility.

8 69. At all times relevant to this action, Defendants owed patients and their

families, including Mr. Lecce and his family, a duty to exercise reasonable care in
10
keeping him, as a vulnerable patient entrusted to their care, safe, sound, secure and with

12 access to appropriate treatment and interventions.

13 70. At all times relevant to this action, Defendants owed patients and their
14
families, including Mr. Lecce and his family, at duty to exercise reasonable care in their
15
search efforts to locate him in a timely manner once his whereabouts became unknown.
16
17 71. At all times relevant to this action, Defendants acted unreasonably with

18 regard to Mr. Lecce and failed to meet the standard of care requirements.
19
72. Mr. Lecce’s death is a direct result of Defendants’ failures. His death has
20
caused, and will forever cause, injury and damage to his surviving beneficiaries.
21
22 73. Pursuant to the provisions of A.R.S. 12- 613 in an action for wrongful

23 death, the jury shall give such damages as it deems fair and just with reference to the
24
injuries resulting in the death of the decedent, Richard Lecce, to the surviving parties who
25
may be entitled to recover having regard for the “aggravating circumstances” attending
26

14
the wrongful acts, neglect or default of the Defendants and/or their employees and agents.
1
2 V. Count Two — Negligence Per Se. (All Defendants)

3 74. Plaintiff incorporates paragraphs 1-73 as though fully set forth herein.
4
75. At all times relevant to this action, Defendants, all of them, were obligated
5
to follow Arizona law, including statutes and regulations, governing the operation of a
6
7 Level One psychiatric hospital and a Level Two residential behavioral health facility.

8 76. Plaintiff’s decedent, Richard Lecce, was in the class of people whom these

statutes and regulations were designed to protect.
10
77. At all times relevant to this action, Defendants violated Arizona law

12 governing the safe, lawful, reasonable, and appropriate operation of a Level One

13 psychiatric hospital and a Level Two residential behavioral health facility, including but
14
not limited to, violations of Arizona Administrative Code R9-20-201, et seq.
15
78. Richard Lecce’s death is a direct and proximate result of Defendants’
16
17 violations of these safety laws, and Mr. Lecce’s surviving statutory beneficiaries have

82. The CFA provides consumers with an implied private cause of action
4
against those who violate the act.
5
83. The elements of a private claim are a false promise, omission, or
6
7 misrepresentation, made in connection with the sale or advertisement of merchandise,

8 and the plaintiff’s consequent and proximate injury from reliance on such a
9
misrepresentation.
10
84. Plaintiff’s reliance need not be reasonable.

12 85. At all times relevant to this action, Defendant Sierra Tucson acted in

13 violation of the CFA through its false, deceptive, and unfair affirmative advertisements in
14
print and online, mcluding but not limited to on its owned and controlled website,
15
www.sierratucson.com.
16
17 86. At all times relevant to this action, Defendant Sierra Tucson acted in

18 violation of the CFA though its material concealment, suppression, and/or omission of
19
material fact including the concerning number of suicides inside its facility, and the
20
related enforcement actions the State of Arizona Department of Health Services had
21
22 taken against its licenses.

23 87. At all times relevant to this action, Plaintiffs relied on the statements and
24
advertisements of Sierra Tucson in selecting Sierra Tucson as the best place for the care
25
and treatment of their vulnerable husband and father.
26

16
88. Once in the care and custody of Defendant Sierra Tucson, Mr. Lecce did
1
2 not receive the promised services. Indeed, Defendant Sierra Tucson knew andlor should

3 have known that it was unable or unwilling to provide the promised services.
4
89. As a direct and proximate result of Plaintiff’s reliance on Sierra Tucson’s
5
false and misleading statements and the absence and concealment of material facts, Mr.
6
7 Lecce suffered the ultimate injury — death — and Plaintiff, individually and on behalf of

8 all statutory beneficiaries, has suffered injury including economic injury for expenses

13 91. In 2006, a patient at Sierra Tucson committed suicide by drowning. Sierra
14
Tucson was a defendant in a wrongful death litigation where the central allegation was a
15
failure to properly supervise a vulnerable patient population.
16
17 92. In 2009, Defendants were fined by the State of Arizona in connection with

of a behavioral health facility.
20
93. In 2011, a patient with a history of anxiety and depression went missing
21
22 from Sierra Tucson’s Level Two residential facility. Two weeks later he was found dead

23 approximately 400 yards from his room, near the facility’s horse stable.
24
25
26

17
94. State regulators took adverse action against Sierra Tucson’s Level Two
1
2 license and fmed the facility as a result of the 2011 death. Sierra Tucson entered into an

3 agreed to Enforcement Action.
4
95. In January 2014, a patient with a history of anxiety hanged himself inside
5
his Level Two Sierra Tucson room. Earlier that same day, his wife had called Sierra
6
7 Tucson staff to report that he had expressed suicidal ideation to her.

8 96. In April 2014, a 20-year-old man, who was in Sierra Tucson for drug

rehabilitation, died of acute drug toxicity.
10
97. In May 2014, state regulators took adverse action against Sierra Tucson’s
11
12 Level Two license and fmed the facility. Sierra Tucson entered into an agreed to

13 Enforcement Action.
14
98. In September 2014, state regulators took adverse action against Sierra
15
Tucson’s Level One license and fined the facility. Sierra Tucson entered into an agreed
16
17 to Enforcement Action.

18 99. Each of these four prior deaths involve a common issue of Sierra Tucson’s
19
ongoing failure to properly monitor and supervise its vulnerable patient population in a
20
manner that causes and/or contributes to their death.
21
22 100. Several of these deaths are the result of Sierra Tucson’s ongoing failures in

23 properly looking for its vulnerable patients when they are absent from scheduled
24 .

activities.
25
26

18
101. The importance of proper patient care and supervision has been known to
1
2 Defendant since it entered the behavioral health care market, and it has known that the

3 consequences of failure to do so can be fatal.
4
102. In sworn testimony, current and former Sierra Tucson employees, including
5
a medical doctor and primary counselor, testified that they had raised concerns to Sierra
6
7 Tucson administration, including the risk manager and executive director, about failures

8 in the facilities patient tracking system and Amber Alert system.

103. The dangers of failing to provide reasonable supervision and care,
10
especially in their open, desert campus location, has been known to Defendants since at

12 least 2006.

13 104. Defendants have known of their own failures to comply with its own
14
policies and state regulations in regard to the supervision and care of patients since at
15
least 2009.
16
17 105. Other problems involving missing patients, patient safety, and unreasonable

18 failures to comply with both policies and procedures and the standard of care have been
19
known or should have been known to Defendants long before January 23, 2015.
20
106. Despite this knowledge, Defendants continued with a business model that
21
22 placed a vulnerable patient population in danger.

23 107. Even subsequent to January 23, 2015, Defendant Sierra Tucson continued
24
with a business model that placed vulnerable patients in danger.
25
26

19
108. Just a few months after Mr. Lecce’s death, on August 27, 2015, another
1
2 vulnerable Sierra Tucson patient took his own life inside Sierra Tucson’s Level Two

3 residential facility.
4
109. The circumstances surrounding the August 27 death are tragically similar to
5
those surrounding the prior five deaths.
6
7 110. It again involved a patient who had expressed suicidal ideation not being

8 engaged with on the date of his death.

111. It again involved Sierra Tucson’s failures to follow its own Amber Alert
10
policy and the standard for care to look for a patient who was absent from scheduled

12 activities.

13 112. Defendant Sierra Tucson’s conduct was such that it was done with an evil
14
mind evidenced by Defendants acting to serve their own interests, having reason to know
15
and consciously disregarding a substantial risk that their conduct might, and in fact did,
16
17 significantly injure the rights, health, or safety of others and/or consciously pursuing a

18 course of conduct knowing that it created a substantial risk of significant harm to others.
19
WHEREFORE, Plaintiff Lindsey Lecce prays for judgment in her favor and
20
against Defendants, all of them, as follows:
21
22 1. For past and future special damages;